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World Health Organization
Interpersonal Violence and Alcohol Policy Briefing

Interpersonal violence (Box 1) and harmIul and hazardous alcohol use
1
are major
challenges to global public health. Both place large burdens on the health oI
populations, the cohesion oI communities and the provision oI public services
including health care and criminal justice. Globally, alcohol is responsible Ior 4 oI
all years oI health lost through premature death or disability (DALYs, disability-
adjusted liIe years |1|), ranging Irom 1.3 in countries in the Islamic Middle East and
Indian subcontinent to 12.1 in Eastern Europe and Central Asia (1). Through
homicide, interpersonal violence results in around 520 000 deaths per year (a rate oI
8.8 per 100 000 population, ranging Irom 3.4 in the World Health Organization
(WHO) Western PaciIic Region to 27.5 in the WHO Region oI the Americas) (2). For
every death resulting Irom interpersonal violence, scores oI Iurther victims require
hospital treatment and many more remain untreated and unrecorded by either health
or criminal justice agencies. Although levels oI alcohol consumption, patterns oI
drinking and rates oI interpersonal violence vary widely between countries, across all
cultures there are strong links between the two. Each exacerbates the eIIects oI the
other with a strong association between alcohol consumption and an individual`s risk
oI being either a perpetrator or a victim oI violence.

Box 1: Interpersonal violence
Interpersonal violence is the intentional use oI physical Iorce or power, threatened or actual, against another
person, that either results in or has a high likelihood oI resulting in injury, death, psychological harm,
maldevelopment or deprivation (2). Interpersonal violence can be categorised into:
Youth violence: Violence committed by young people.
Child maltreatment: Violence and neglect towards children by parents and caregivers.
Intimate partner violence: Violence occurring within an intimate relationship.
Elder abuse: Violence and neglect towards older people by Iamily, carers or others where
there is an expectation oI trust.
Sexual violence: Sexual assault, unwanted sexual attention, sexual coercion and sexual traIIicking.

The links between alcohol use and interpersonal violence

The mechanisms linking alcohol and interpersonal violence are maniIold.
HarmIul alcohol use directly aIIects physical and cognitive Iunction (3). Reduced
selI-control and ability to process incoming inIormation makes drinkers more
likely to resort to violence in conIrontations (4), while reduced ability to
recognise warning signs in potentially violent situations makes them appear easy
targets Ior perpetrators (5, 6).

1
HarmIul use oI alcohol is deIined as a pattern oI alcohol use that causes damage to health. Hazardous
alcohol use is deIined as a pattern oI alcohol use that increases the risk oI harmIul consequences Ior the
user (World Health Organization, http://www.who.int/substanceabuse/terminology/wholexicon/en/).

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Individual and societal belieIs that alcohol causes aggressive behaviour can lead
to the use oI alcohol as preparation Ior involvement in violence, or as a way oI
excusing violent acts (7, 8).
Dependence on alcohol can mean individuals Iail to IulIill care responsibilities
(9) or coerce relatives into giving them money to purchase alcohol or cover
associated costs (10).
Experiencing or witnessing violence can lead to the harmIul use oI alcohol as a
way oI coping or selI-medicating (11,12).
UncomIortable, crowded and poorly
managed drinking settings contribute to
increased violence among drinkers (13,14).
Alcohol and violence may be related
through a common risk Iactors (e.g. anti-
social personality disorder |15|) that
contribute to the risk oI both heavy drinking and violent behaviour.
Prenatal alcohol exposure resulting in Ietal alcohol syndrome or Ietal alcohol
eIIects are associated in inIants with increased risk oI their maltreatment, and
with delinquent and sometimes violent behaviour in later liIe,

including
delinquent behaviour, sexual violence and suicide (16).

Magnitude of alcohol-related interpersonal violence
Levels and patterns oI alcohol consumption vary widely between countries (Table 1).
Similarly, levels oI violence diIIer between countries. Rates oI mortality Ior
intentional injury range Irom around 4 per 100 000 population in Georgia, Kuwait and
Greece to over 50 per 100 000 in the Russian Federation, El Salvador and Colombia
(2).
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Table 1. Levels and patterns of alcohol consumption bv WHO Region
WHO Regions
a

Total
consumption
(all people)
b

Proportion
of drinkers
Consumption
per drinker
c

Pattern
d

Low to Middle Income Countries
Very high or
high mortality:
lowest
consumption
Islamic middle east
and Indian
subcontinent
(EMR-D, SEAR-D)
1.88 15.0 12.27 2.9
Very high or
high mortality:
low
consumption
Poorest countries in
AIrica and America
(AFR-D, AFR-E, AMR-D)
5.93 42.8 14.21 2.8
Low mortality
emerging
economies
Better-oII developing
countries in America,
Asia, PaciIic (AMR-B,
EMR-B, SEAR-B, WPR-B)
5.23 51.0 10.53 2.4
High Income Countries
Very low
mortality
North America,
Western Europe,
Japan, Australasia.
(AMR-A, EUR-A, WPR-A)
10.90 77.8 14.00 1.5
Former
socialist: low
mortality
Eastern Europe and
Central Asia (EUR-B,
EUR-C)
11.42 74.5 15.09 3.3
World 6.03 48.6 12.26 2.5
Source: Room et al 2005 (1)
a
Regional sub groupings deIined by WHO on the basis oI mortality levels (see World Health Report
2002, available Irom: http://www.who.int/whr/2000/en/index.html).
b
Litres oI pure alcohol per resident aged 15 and over per year (recorded and unrecorded consumption).
c
Litres oI pure alcohol per resident drinker aged 15 and over per year (recorded and unrecorded
consumption).
d
Indicator oI hazard per litre oI alcohol consumed, composed oI several indicators oI heavy drinking
occasions, Irequency oI drinking in public places plus Irequency oI drinking with meals (reverse
scored). Range, 1least detrimental, 4most detrimental.

Few countries routinely measure the involvement oI alcohol in violence. Further, most
recording systems and research examining alcohol use by victims and perpetrators oI
violence derive Irom high-income countries. Even where estimates oI alcohol`s role in
violence are available, methodological diIIerences between studies complicate direct
comparisons between countries. However, across countries, harmIul alcohol use is
estimated to be responsible Ior 26 oI male and 16 oI Iemale DALYs lost through
homicide (17). Furthermore, the role oI harmIul alcohol consumption as a risk Iactor
Ior violent victimization and perpetration, and the impact oI violent experiences on
Iuture drinking behaviours, are increasingly being identiIied throughout the world.
Findings Irom a review oI global scientiIic literature include the Iollowing.

Harmful alcohol consumption bv perpetrators of violence
In the USA, among victims that were able to report whether their attacker had been
using alcohol, 35 believed the oIIender had been drinking (18).
In England and Wales, 50 oI victims oI interpersonal violence reported the
perpetrator to be under the inIluence oI alcohol at the time oI assault (19).
In Russia, around three-quarters oI individuals arrested Ior homicide had consumed
alcohol shortly beIore the incident (20).
In South AIrica, 44 oI victims oI interpersonal violence believed their attacker to
have been under the inIluence oI alcohol (21).
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In Tianjin, China, a study oI inmates Iound that 50 oI assault oIIenders had been
drinking alcohol prior to the incident (22).

Harmful alcohol consumption bv victims of violence
In Australia, 26 oI male and 17 oI Iemale homicide victims (2002-2003) had
been drinking just prior to death (23).
Between 1970 and 1998, 36 oI victims oI violence presenting to a trauma
department in the Netherlands had consumed alcohol (24).
Among victims oI violent injuries presenting to emergency rooms in six countries
2
,
the percentage testing positive Ior alcohol
3
ranged Irom 24 in Argentina to 43
in Australia (25).
Between 1999 and 2001, between 43 and 90 oI victims presenting to hospital
trauma units in three South AIrican cities tested positive Ior alcohol (26).
In So Paulo, Brazil, 42 oI homicide victims were shown to have used alcohol
prior to death (2001) (27); and 46 oI assault victims presenting to a trauma
centre tested positive Ior alcohol (1998-1999) (28).

HarmIul alcohol use is a risk Iactor across all types oI interpersonal violence. Victims
are less likely than perpetrators to be under the inIluence oI alcohol during an incident
(29), and Ior many victims harmIul levels oI alcohol use can occur later as a
consequence oI violent experiences (Table 2).


2
Argentina, Australia, Canada, Mexico, Spain, the USA.
3
For countries where 95 or more patients were tested.
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Table 2. Alcohol misuse as a risk factor for and a consequence of violence

Alcohol misuse as a risk factor for
violence
Alcohol misuse as a consequence of
violence
Child
maltreatment
In Germany, 32 oI oIIenders oI Iatal
child abuse (1985-90) were thought to
have consumed alcohol prior to the
oIIence (30). Parental alcohol or drug use
was reported in 34 oI child welIare
investigations in Canada (31).
Globally, a history oI child sexual abuse is
estimated to cause 4-5 oI alcohol misuse
in men and 7-8 in women (32).
Youth
violence
In Israel, 11-16 year olds who reported
both drinking Iive or more drinks per
occasion and having ever been drunk
were twice as likely to be a perpetrator oI
bullying, Iive times as likely to be injured
in a Iight and six times as likely to carry a
weapon (33).
In the USA, victims oI violence during
adolescence report higher levels oI alcohol
consumption in later liIe (34).
Intimate
partner
violence
In Russia, 60-75 oI male perpetrators oI
intimate partner homicides had been
drinking (35). In Iceland, 71 oI Iemale
victims oI intimate partner violence stated
partner alcohol use as the main cause oI
their assault

(36).
In Iceland, 22 oI Iemale intimate partner
violence victims reported using alcohol
Iollowing the event as a mechanism Ior
coping (36).
In the USA, 44 oI male and 14 oI
Iemale abusers oI elderly parents (age 60
years and over) were dependent on
alcohol or drugs, along with 7 oI
victims (37).
In Canada, an outreach program Ior
seniors with alcohol or other substance
misuse problems reported 15-20 oI
clients experiencing some Iorm oI elder
abuse. For some, alcohol use was a way oI
coping with violent experiences (38).
Sexual
violence
In the United Kingdom, 58 oI men
imprisoned Ior rape reported having
consumed alcohol in the six hours
preceding the oIIence and 37 were
considered to be alcohol dependent (39).
In the USA, victims oI sexual assault
report higher levels oI psychological
distress and the consumption oI alcohol, in
part, to selI-medicate (40).


Risk factors for alcohol-related interpersonal violence
A wide range oI Iactors can increase individuals` risks oI being either a perpetrator or
victim oI alcohol-related violence. To help understand these Iactors and how they
interact,

an ecological model (2) (Figure 1) is used to divide risk Iactors into those
associated with the individual, relationships between individuals, communities and
society. Risk Iactors Ior each are summarised below.

Figure 1: The ecological model for understanding violence


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Individual Factors

Victims
Age: Alcohol-related assaults are experienced more Irequently among young
adults. For instance in England and Wales and Australia, 16-29 year olds (41),
and 15-34 year olds respectively (42) are at increased risk.
Gender: In general, males are at higher risk oI alcohol-related interpersonal
violence requiring hospital treatment. In studies oI hospital admissions, males
accounted Ior the majority oI all alcohol-related assault victims (e.g. Australia
74 |42|, England 80 |43|) and in one Kenyan study oI emergency
department presentations Ior injury were approximately twice as likely as
Iemales to have been drinking alcohol prior to assault (44).
Drinking patterns: High levels oI alcohol consumption have been associated
with increased risk oI experiencing violence (41), with those who report more
Irequent intoxication most likely to be involved in an alcohol-related assault
(45). Further, early initiation into alcohol use has been associated with
increased risk oI sexual victimisation in adolescence (46).
Experience of violence: Individuals who experience violence in childhood (47,
48) and adulthood (49) can be at greater risk oI alcohol dependence later in
liIe. Further, adults who have suIIered more than one type oI violence (e.g. by
an intimate partner and a stranger) have higher rates oI alcohol problems than
those who have experienced only one type (49).

Perpetrators
Age: Risk oI perpetration varies with age. In the USA, 38 oI oIIenders oI
alcohol-related violent crime are aged 30-39, and a Iurther 29 aged 21-29
(18). In the United Kingdom, alcohol-related violence towards strangers is
more likely to be committed by 16-24 year olds and that towards
acquaintances by those aged 25 years and older (41).
Gender: Perpetrators oI alcohol-related violence are more likely to be male
(e.g. Norway |50|; England and Wales |41|).
Drinking patterns: Heavier and more Irequent drinkers are more at risk oI
perpetrating violence (e.g. Norway |45|, Latin America and Spain |51|), as are
those that start drinking alcohol at an earlier age (52).
Personalitv: The relationship between alcohol and violence is mediated by
certain characteristics such as an antisocial personality, which increases the
risk oI a person becoming aggressive aIter drinking (15).
Relationship factors
Drinking patterns: Discrepant drinking patterns (i.e. only one partner is a
heavy drinker) have been Iound to increase the risk oI intimate partner
violence (53).
Exposure to violence: Experience oI parental violence in childhood is
associated with the development oI alcohol-related problems later in liIe (54).
Parental use of alcohol: A young person`s risk oI violent oIIending is
increased iI their parent (particularly their mother) engages in harmIul use oI
alcohol (55).
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Acquaintances: A higher risk oI alcohol-related criminal and disorderly
oIIending is Iound among those who associate with delinquent acquaintances
(56).

Community factors
Time of dav and dav of week. Alcohol-related assaults occur most Irequently
at night and particularly at weekend nights (England and Wales |41|, Kenya
|44|).
Drinking venues. Greater concentrations oI drinking venues within an area
have been Iound to increase the risk oI interpersonal violence in that area (57).
Characteristics of licensed premises: Premises that are uncomIortable (e.g.
crowded, lacking seating and ventilation, hot and noisy); unattractive and
poorly maintained; oIIer discounted alcoholic drinks; employ aggressive door
supervisors; have a high proportion oI intoxicated patrons, or have a
permissive attitude towards anti-social behaviour (e.g. serving underage or
drunk customers and allowing swearing and overt sexual activity) are more
associated with violent behaviour (14,58,59).

Societal factors
Riskv drinking culture: Across studies in seven countries
4
, the percentage oI
violence-related injuries associated with harmIul alcohol use was higher in
societies that had greater alcohol consumption per capita (60). Societies
characterized by heavy episodic drinking suIIer higher levels oI alcohol-
related violence (61) than societies where alcohol use is high but more
integrated into daily routines (e.g. mealtimes) (60).
Societal beliefs and attitudes: BelieIs that alcohol has disinhibiting eIIects
encourage the harmIul use oI alcohol as an excuse Ior violent behaviour (such
as youth violence; Sweden |62|) or to Iuel the audacity necessary to commit
crimes (including violent crimes; South AIrica |63|). Also in South AIrica,
rape can result Irom men who buy drinks Ior women and subsequently think
they are owed sexual Iavours in return (64).

Impact
Across all countries, alcohol-related violence has Iar-reaching consequences, aIIecting
the health and well being oI victims, relationships with Iamily and Iriends, levels oI
Iear within communities, and pressures on health and other public services (Box 2).
For victims, health impacts include physical injuries and emotional harm such as
depression, anxiety and sleep problems (65,41). In England and Wales, around three-
quarters oI victims oI assault experience some Iorm oI subsequent emotional harm
(41). HarmIul alcohol use is oIten cited as a method oI coping with violent
experiences (12) and victims are more likely to develop problematic drinking habits
later in liIe (47-49). Other longer-term health eIIects can include suicide and post-
traumatic stress disorder (65-68) (Box 3).

Research in high-income countries has Iound that alcohol consumption by both
victims and perpetrators oI violence can increase the severity oI injuries (69,70).
Furthermore, in serious assaults alcohol may play a role in determining victims`

4
US, Mexico, Canada, Australia, Spain, Argentina, Poland
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survival, Ior example by reducing their ability to seek urgent medical assistance or
reducing perceptions oI the seriousness oI injury (71).

Social problems resulting Irom the experience oI violence oIten aIIect victims`
relationships with Iamily, Iriends and Iuture intimate partners (76), as well as their
ability to work or attend school (76,77). Children who witness violence, or threats oI
violence, between their parents are more likely to develop emotional and behavioural
problems during childhood (78) and heavy
drinking patterns or alcohol dependency
later in liIe (79), increasing their risk oI
becoming perpetrators oI violence. A high
prevalence oI alcohol-related violence
within a community can also aIIect quality
oI liIe, reducing community cohesion,
increasing Iear oI crime and preventing
people Irom visiting places associated with
disorder such as city centres at night (80),
or using public transport (81).

The burden oI alcohol-related violence on
public service provision and the economy
can be immense. For health and criminal
justice agencies, apprehending and treating
oIIenders and victims oI alcohol-related
violence is Iinancially costly (Box 2) and diverts resources Irom other health and
crime issues. Furthermore, health and judicial staII can Irequently be victims oI
alcohol-related violence themselves whilst at work (84), and this may encourage both
employees and prospective employees to consider alternative careers.

Prevention
Although alcohol consumption is a normal and acceptable part oI society throughout
much oI the world, violence associated in particular with hazardous and harmIul
consumption poses an important but preventable problem. Central to prevention is
creating societies and environments that discourage risky drinking behaviours and do
not allow alcohol to be used as an excuse Ior violence. The evidence base Ior the
eIIective prevention oI alcohol-related violence is mainly Irom high-income countries.
Much less is known about the eIIectiveness oI interventions elsewhere with
diIIerences in drinking cultures, societal attitudes towards violence and laws
surrounding the sale and consumption oI alcohol being important considerations.

Box 2: Economic costs of alcohol-related violence
The economic costs oI alcohol-related violence include direct costs such as those to healthcare and
judicial services, and indirect costs such as work and school absenteeism. Estimates oI the
economic costs oI violence and the proportion oI violence related to alcohol include:
USA: US$46.8 billion (72) to US$425 billion (73) per year, depending on the type oI costs
included. An estimated 35 oI violence is related to alcohol (18).
England and Wales: 24.4 billion per year (74) (approximately US$42.7 billion) (excluding
violence towards children aged less than 16 years and elders over 65 year oI age), around 2
GDP. An estimated 50 oI violence is related to alcohol (19).
Latin America: Estimated percentages oI GDP lost due to violent crime (1997) including
collective violence range Irom 1.3 in Mexico to 24.9 in El Salvador (75), although the
proportion related to alcohol is not known.
Box 3: Alcohol and suicide
Suicide can be a consequence oI
interpersonal violence. There is also a strong
relationship between alcohol consumption
and suicide or attempted suicide, especially
among those who drink heavily. In this
group the risk oI suicidal behaviour
increases iI other mental health problems
such as depression are present.
Approximately 7 oI people with alcohol
dependence die through suicide (82).
Suicide rates rise with increased per capita
consumption, and tend to be higher in
drinking cultures characterized by irregular
heavy drinking, in common with
interpersonal violence (83). EIIective
interventions that reduce heavy drinking
may reduce both assaults and suicide.
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For interpersonal violence in general, early interventions such as pre- and post-natal
services can be eIIective prevention measures and these strategies have been
thoroughly reviewed elsewhere (2). SpeciIically Ior alcohol-related violence,
interventions to reduce population alcohol consumption (e.g. regulating alcohol sales)
have proven eIIective in reducing levels oI violence both in low-to middle-income
and high-income countries. However, interventions to modiIy drinking settings (e.g.
improving licenced premise management), screen Ior harmIul drinking and conduct
brieI interventions, treat alcohol dependence, and improve drinking environments
have been Iound to be eIIective in high-income countries, but are largely untested
elsewhere (See Box 4).

Several important Iactors impinge on the applicability oI prevention strategies in low-
to middle-income countries. In many low- to middle-income societies, a large
proportion oI alcohol consumed is produced at home. Thus, strategies to reduce
alcohol consumption through increased price (e.g. higher taxation) may be less
eIIective and may switch drinkers to cheaper, home produced alcohol (85). In some
low- and middle-income countries, the enactment and enIorcement oI legislation on
the legal minimum age Ior purchase oI alcohol, and eIIorts to strengthen and expand
the licensing oI liquor outlets could be oI great value in reducing alcohol-related
violence. For example, there is no legal minimum age oI sale Ior alcohol in the
Gambia, and in South AIrica it is estimated that 80-90 oI liquor outlets are
unlicensed (86). In contrast, in high-income countries the the majority oI alcohol
outlets are licensed, most alcohol is produced by industry and laws to restrict access to
alcohol by minors are enIorced. More research is needed in low- to middle-income
countries to identiIy successIul interventions Ior preventing alcohol-related violence
and to examine opportunities to regulate production and sale.

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Box 4: Interventions to prevent alcohol-related violence

Increasing alcohol prices
Increased alcohol prices through higher taxation can reduce levels oI violence (93). In the USA, it has been
estimated that a 1 increase in the price oI alcohol will decrease the probability oI wiIe abuse by about 5
(94), while a 10 increase in the excise tax on beer will reduce the likelihood oI severe child abuse by
around 2 (95). However, regional and international trade agreements can hamper national eIIorts to
inIluence alcohol prices. Such agreements resulted in a 45 decrease in tax on spirits in Finland and
Denmark and increased spirit sales by 20 (96). Locally, minimum price policies can reduce access to
cheap alcohol in licensed premises iI adhered to by all vendors (97). Interventions to increase alcohol prices
however should also seek to control illegal alcohol production and smuggling.

Regulating alcohol sales
Reducing the availability oI alcohol can reduce consumption levels and related violence. In Diadema,
Brazil, prohibiting the sale oI alcohol aIter 23:00 helped prevent an estimated 273 murders over 24 months
(87); conversely, removal oI the government monopoly on oII-licence beer sales in Finland led to a 46
increase in consumption and increased alcohol problems (88). Bans on alcohol sales that are implemented
during certain periods, such as Iootball matches, can be eIIective in reducing levels oI assaults (89). In some
countries (e.g. the United Kingdom) permanent location-speciIic bans are used to prevent alcohol
consumption in public areas associated with alcohol-related disorder such as town and city centre streets.
Such bans have also been implemented on a temporary basis Ior speciIic Iestivals (e.g. Cape Town, South
AIrica beaches during Christmas) (86).

Reduce access to alcohol by young people
At an individual level, early age oI Iirst alcohol use is related to increased risk oI violence. Where laws
exist, minimum legal age oI alcohol purchase ranges Irom 15 (e.g. Slovenia) to 21 (e.g. USA) yet underage
sales can be common (98). These sales can be reduced through server training programmes and strict
enIorcement oI age oI purchase legislation (e.g. through test purchasing and penalties including license
revocation |99|).

Modifying drinking settings
Drinking venues that are poorly managed are associated with higher levels oI violence (90). Interventions to
improve management practice include training programmes Ior managers and staII (91), use oI licensing
legislation to enIorce change (e.g. door supervisor training) and implementation oI codes oI practice. In
Australia, a community-based initiative to improve management practice oI drinking venues in North
Queensland led to a reduction in arguments (by 28), verbal abuse (by 60) and challenges or threats (by
41) within those premises (92).

Screening and brief interventions
Alcohol screening (e.g. AUDIT |100|) and brieI interventions (101) in health settings can be eIIective in
reducing alcohol consumption among victims oI alcohol-related violence (102). Screening can also be used
to identiIy victims oI alcohol-related violence. Key locations Ior screening include emergency departments
and pre-natal services. In the USA, a cost beneIit analysis oI brieI interventions to reduce levels oI alcohol
consumption among patients with alcohol-related trauma estimated that $3.81 in health care costs would be
saved Ior every $1.00 spent on screening and interventions (103).

Treatment for alcohol dependence
Treatment Ior alcohol dependence can be eIIective in reducing levels oI alcohol consumption and associated
problems such as violent behaviour. For instance, a USA study Iound that treatment Ior alcohol dependence
among males signiIicantly decreased both husband-to-wiIe physical and psychological violence, and wiIe-
to-husband violence six and 12 months later (104).

Legal interventions
Legal interventions can be employed to deter individuals Irom excessive drinking and related violence.
These include the use oI Iines Ior alcohol-related disorderly conduct or being intoxicated in public, and
banning orders preventing troublemakers Irom using licenced premises. However, there are Iew evaluations
oI such measures and their preventive value is unclear.

Improving the wider night-time environment
Large concentrations oI intoxicated individuals in town and city centres can lead to violence, while
intoxicated individuals are vulnerable to assault when walking home on dark streets (105). Interventions
such as the provision oI saIe late-night transport (92), improvements to street lighting (106) and the use oI
closed circuit television (CCTV) (107) can help reduce alcohol-related violence around licenced premises.
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The role of public health
In all countries, health services have a central role to play in the prevention oI
alcohol-related violence (Box 5).


Information svstems and data
Health services are ideally placed to collate and disseminate a wide range oI
inIormation on drinking patterns and the use oI health service settings Ior violence-
related injury and alcohol problems. Whilst much oI this inIormation is available to
varying degrees in many high-income countries, there is oIten a lack oI inIrastructure
in place to assess the role oI alcohol in violence elsewhere (85). However, such
inIormation is essential to describing the extent oI the problem and identiIying
population groups and geographical areas most at risk oI alcohol-related violence.
Recognising that diIIerent countries have varying levels oI resources and
inIrastructure in place to monitor alcohol consumption and related harm, the World
Health Organization published international guidelines in 2000. These provide
inIormation to assist countries in developing an epidemiological monitoring system to
inIorm eIIective policy and to improve global and regional comparability oI data on
alcohol use and associated harm (108).

Services for victims of violence and alcohol misusers
In high-income countries, brieI interventions in health settings have proven eIIective
in reducing risky drinking among victims oI alcohol-related violence while screening
Ior exposure to violence can enable victims to be identiIied and supported. StaII in
trauma departments, Ior example, are well placed to screen Ior hidden victims oI child
maltreatment (109), elder abuse (110), sexual violence (111)

and intimate partner
violence (112). Such interventions should be widely implemented but require
investment in training and support Ior health staII. Moreover, so that victims can be
oIIered support, adequate eIIective services must be available to cope with the
resulting increases in demand.

Advocacv, collaboration and promoting prevention
Public health proIessionals should promote a multi-sectoral approach to prevention
with the roles oI the contributors deIined according to their capacity to alter one or
more oI the risk Iactors Ior alcohol-related violence. Potential stake holders include
health services, criminal justice agencies, local authorities, the liquor industry, grass-
roots organizations, media and local residents (See Box 6). Such an approach should
highlight the links between harmIul alcohol use and violence, their impacts on the
targets oI other agencies (e.g. education |113| and business proIitability |114|) and the
eIIectiveness and cost-eIIectiveness oI interventions. Public health initiatives should
promote a holistic prevention approach (115), ensuring, Ior example, that eIIorts to
reduce the availability oI cheap alcohol in nightliIe settings do not simply displace
alcohol and violence problems to other areas. Such initiatives should also advocate Ior
Box 5: The Role of Health Services
Collating and disseminating inIormation on the size oI the problem and at-risk groups.
IdentiIying, supporting and treating victims oI alcohol-related violence.
Catalysing multi-sectoral collaboration Ior prevention.
Advocating Ior policy to reduce risky drinking and violence.
IdentiIying, inIorming, implementing and monitoring eIIective interventions.
Promoting, conducting and evaluating research on the links between alcohol and violence and
the costs to society.

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early developmental interventions, such as reducing maltreatment during inIancy as a
means oI preventing the consequent development oI harmIul alcohol use and violent
tendencies in later liIe. With such interventions some results can take years to
materialize and health services can play a major role in securing the necessary longer-
term political support to establish and maintain such prevention initiatives.



Policy
Both the harmIul and hazardous use oI alcohol and violence have been recognized
internationally as key public health issues requiring urgent attention. At national and
international levels, health organizations have a key role in advocating Ior policies
that address the relationships between alcohol use and violence and in doing so
promote prevention initiatives that will improve public health. The World Health
Organization (WHO) runs comprehensive programmes on both issues to instigate and
conduct research, identiIy eIIective prevention measures, and promote action by
Member States to implement successIul interventions and align policy towards
reducing hazardous and harmIul drinking and violence.

For alcohol, this includes collating and disseminating scientiIic inIormation on
alcohol consumption, developing global and regional research and policy initiatives
on alcohol, supporting countries in increasing national capacity Ior monitoring alcohol
consumption and related harm, and promoting prevention, early identiIication and
management oI alcohol use disorders in primary health care (118). A World Health
Assembly resolution on Public health problems caused bv harmful use of alcohol
(WHA58.26 |119|) oI 2005 recognizes the health and social consequences associated
with harmIul alcohol use and requests Member States to develop, implement and
evaluate eIIective strategies Ior reducing such harms, while calling on WHO to
provide support to Member States in monitoring alcohol-related harm, implementing
and evaluating eIIective strategies and programmes, and to reinIorce the scientiIic
evidence on eIIectiveness oI policies.

Box 6: Multi-component community-based violence prevention projects

The DESEPAZ programme in Colombia
In response to increasing levels oI violence in the city oI Cali, Colombia the mayor led the
development oI the DESEPAZ programme, comprising a partnership oI demobilized guerrillas,
labour union representatives, church members and private sector leaders. The programme involved
the development oI an accurate inIormation system Ior measuring violence and a wide range oI
measures to improve law enIorcement (including education and training Ior police); increase
communication between citizens and law enIorcement agencies; and improve education and
employment Ior residents and particularly high-risk youths. Recognizing the important role oI
alcohol in violence, alcohol sales were restricted with closing times imposed on bars and
nightclubs. Both hospitals and traIIic authorities reported reductions in injuries Iollowing this
intervention (116).

The STAD project in Stockholm
In Stockholm, Sweden, the 10-year STAD project (Stockholm prevents alcohol and drug
problems) has, among other things, developed a programme together with local authorities and the
hospitality industry. The programme incorporated community mobilization (e.g. establishment oI
an advisory group including the licenced trade, police, health services and the local council),
responsible beverage service training (covering alcohol legislation, health eIIects oI alcohol and
conIlict management) and enIorcement activity (including Iormal warnings and licence
withdrawals Ior Iailing to adhere to licencing legislation). Evaluation oI the programme Iound a
29 reduction in violent crime in the intervention area (117).

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For violence, this includes the WHO Global Campaign Ior Violence Prevention.
Launched in 2002, the Campaign aims to raise international awareness about the
problem oI violence, highlight the role oI public health in its prevention, and increase
violence prevention activities globally, regionally and nationally. The approach to
preventing violence is set out in the WHO World report on violence and health (2).
World Health Assembly resolution WHA56.24 (120) oI 2003 encourages Member
States to implement the recommendations set out in the report, and calls on the
Secretariat to cooperate with Member States in establishing science-based public
health policies and programmes Ior the implementation oI measures to prevent
violence and to mitigate its consequences. Complementary to this, the Violence
Prevention Alliance has been established to provide a Iorum Ior the exchange oI best
practice inIormation between governments and other agencies working to reduce
violence around the world.

The United Nations also conducts a range oI programmes to address the diIIerent
Iorms oI violence globally, with alcohol recognized as a major risk Iactor. For
example, UNIFEM, the United Nations (UN) Development Fund Ior Women,
provides Iinancial and technical assistance to programmes that promote women's
empowerment and gender equality and works with countries to Iormulate and apply
laws and policies to eliminate violence against women. Through UNICEF, the United
Nations Children`s Fund, the UN Study on Violence Against Children aims to urge
governments across the world to IulIil their duty to end such violence, and the UN
Guidelines Ior the Prevention oI Youth Delinquency (The Riyadh Guidelines)
speciIically state that attention be given to strategies to prevent alcohol and drug use
among young people.


Challenges
Already in some countries dangerous drinking patterns have become embedded
especially in youth culture, with people routinely drinking at hazardous levels (e.g.
Denmark, Ireland, UK |121|). SuccessIully changing hazardous drinking patterns is a
substantial challenge. However, in a number oI countries patterns oI alcohol use are,
in general, less hazardous and relationship between alcohol consumption and violence
is less pronounced. In countries that traditionally have not used alcohol but where,
partially due to globalization alcohol use is now rapidly increasing, a major challenge
is to develop culturally appropriate social norms and other mechanisms to control the
hazardous and harmIul use oI alcohol. Such variations in patterns oI alcohol use and
alcohol-related violence provide the opportunity to examine and exchange
inIormation (Ior instance through the Violence Prevention Alliance) on how and why
it is curbed in some regions but increasing in others. Low- to middle-income countries
Iace additional challenges Ior reducing alcohol-related violence. Here, relatively
unregulated alcohol production and sales call Ior the enactment and enIorcement oI
laws to regulate alcohol availability, and there is little evidence Ior what alternative
interventions may be successIul. Even in high-income countries implementation oI
evidence-based interventions and policy is oIten complicated by major economic
interests in the production and sale oI alcohol. Consequently, minimizing alcohol-
related violence requires strong leadership and the political will to tackle a substance
used widely throughout populations. However, the interests oI communities and
companies alike are served when the threats to public health posed by interpersonal
violence and alcohol are minimized. While there are no easy solutions to addressing
alcohol-related violence, the growing body oI international research means that a
World Health Organization
Page 14
clearer picture is developing oI how alcohol and violence are related and what
strategies can be eIIective in prevention.

Priorities for Action
Interventions that address the public health eIIects oI harmIul use oI alcohol in
general should Iorm the Iramework Ior more speciIic interventions designed to
prevent alcohol-related violence. Priorities Ior speciIic actions on alcohol-related
violence include the Iollowing.
Policies and strategies Ior addressing alcohol-related violence should concentrate
expenditure on evidence-based interventions. Where evidence is lacking
investment in novel interventions should be accompanied by rigorous evaluation.
Best practice Ior the reduction oI alcohol-related violence in a number oI settings
should be developed and disseminated.
Investment is required in international research on the links between alcohol and
all Iorms oI interpersonal violence, their costs to society and eIIective prevention
measures, particularly Ior low- to middle-income countries.
Sustained eIIorts should be made to increase awareness oI the links between
alcohol and violence Ior both victims and perpetrators.
International approaches to alcohol taxation should consider public health
priorities and not only the trade and economic aspects.
Countries and regions should aim to improve and standardise recording oI alcohol
involvement in violence in both health and criminal justice settings.
At all levels policy should aim to reduce any alcoholic beverage promotions or
other eIIorts that increase alcohol consumption or encourage the rapid
consumption oI high levels oI alcohol.
Regional and international eIIorts should aim to address the signiIicant immediate
and long-term costs oI alcohol consumption among young people, particularly
through multi-sectoral initiatives to delay the onset oI drinking, reduce illegal
purchase and decrease overall consumption levels.

For further information please consult:
http://www.who.int/violenceinjuryprevention
http://www.who.int/substanceabuse/en
http://www.who.int/substanceabuse/terminology/wholexicon/en

Or contact:
Department oI Injuries and Violence Prevention
Dr Alexander Butchart (butchartawho.int, Iax: 41-22-791-4332,
telephone: 41-22-791-3480)

Department oI Mental Health and Substance Abuse
Dr Vladimir Poznyak, (poznyakvwho.int, Iax 41-22-791-4160,
telephone 41-22-791-4307)

World Health Organization
20 Avenue Appia
CH-1211 Geneva 27, Switzerland


World Health Organization
Page 15
Useful Resources

WHO global status report on alcohol 2004. Geneva, World Health Organization,
2004.

Global status report. alcohol policv. Geneva, World Health Organization, 2004.

Krug EG et al., eds. World report on violence and health. Geneva, World Health
Organization, 2002.

Babor T et al. Alcohol. no ordinarv commoditv. Research and public policv. New
York, OxIord University Press, 2003.

Room R et al. Alcohol in developing societies. a public health approach. Helsinki and
Geneva, Finnish Foundation Ior Alcohol Studies and World Health Organization,
2003.

World Health Organization. International guide for monitoring alcohol consumption
and related harm. http://whqlibdoc.who.int/hq/2000/WHOMSDMSB00.4.pdI.
Accessed 10th October 2005.

Violence Prevention Alliance: http://www.who.int/violenceprevention/en/index.html.

United Nations Development Fund Ior Women (UNIFEM): http://www.uniIem.org/

United Nations Children`s Fund (UNICEF): http://www.uniceI.org/

World Health Organization
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